Intrauterine device#Inert and copper-based devices

The history of intrauterine devices dates back to the early 20th century. Unlike modern intrauterine devices, early interuterine (from Latin {{wikt-lang|en|inter-}}, meaning "between", as opposed to {{wikt-lang|en|intra-}}) devices crossed both the vagina and the uterus, causing a high rate of pelvic inflammatory disease. The first IUD was developed in 1909 by the German physician Richard Richter, of Waldenburg. His device was made of silkworm gut and was not widely used.{{cite journal |vauthors=Thiery M |date=March 1997 |title=Pioneers of the intrauterine device |url=http://www.contrel.be/Articles%20and%20videos/Pioneers%20of%20the%20intrauterine%20device.pdf |journal=The European Journal of Contraception & Reproductive Health Care |volume=2 |issue=1 |pages=15–23 |doi=10.1080/13625189709049930 |pmid=9678105 |archive-url=https://web.archive.org/web/20060820044102/http://www.contrel.be/Articles%20and%20videos/Pioneers%20of%20the%20intrauterine%20device.pdf |archive-date=August 20, 2006}}

Ernst Gräfenberg, another German physician (after whom the G-spot is named), created the first Ring IUD, Gräfenberg's ring, made of silver filaments. His work was suppressed during the Nazi regime, when contraception was considered a threat to Aryan women. He moved to the United States, where his colleagues H. Hall and M. Stone took up his work after his death and created the stainless steel Hall-Stone Ring. A Japanese doctor named Tenrei Ota also developed a silver or gold IUD called the Precea ring ({{Translation|pressure ring}}) or Ōta ring.

Jack Lippes helped begin the increase of IUD use in the United States in the late 1950s. In this time, thermoplastics, which can bend for insertion and retain their original shape, became the material used for first-generation IUDs. Lippes also devised the addition of the monofilament nylon string, which facilitates IUD removal. His trapezoid shape Lippes Loop IUD became one of the most popular first-generation IUDs. In the following years, many different shaped plastic IUDs were invented and marketed. These included the infamous Dalkon Shield, whose poor design caused bacterial infection and led to thousands of lawsuits. Although the Dalkon shield was removed from the market, it had a lasting, negative impact on IUD use and reputation in the United States.{{cite journal |vauthors=Thiery M |date=June 2000 |title=Intrauterine contraception: from silver ring to intrauterine contraceptive implant |journal=European Journal of Obstetrics, Gynecology, and Reproductive Biology |volume=90 |issue=2 |pages=145–152 |doi=10.1016/s0301-2115(00)00262-1 |pmid=10825633}} Lazar C. Margulies developed the first plastic IUD using thermoplastics in the 1960s.{{cite journal |vauthors=Thiery M |date=March 1997 |title=Pioneers of the intrauterine device |url=http://www.contrel.be/Articles%20and%20videos/Pioneers%20of%20the%20intrauterine%20device.pdf |journal=The European Journal of Contraception & Reproductive Health Care |volume=2 |issue=1 |pages=15–23 |doi=10.1080/13625189709049930 |pmid=9678105 |archive-url=https://web.archive.org/web/20060820044102/http://www.contrel.be/Articles%20and%20videos/Pioneers%20of%20the%20intrauterine%20device.pdf |archive-date=20 August 2006 |access-date=24 March 2016}} His innovation allowed insertion of the IUD into the uterus without the need to dilate the cervix.{{Cite book |url=https://books.google.com/books?id=aNn_AwAAQBAJ&q=%22Lazar%20C.%20Margulies%22&pg=PA306 |title=The Birth Control Movement and American Society: From Private Vice to Public Virtue |vauthors=Reed J |publisher=Princeton University Press |year=1984 |isbn=978-1-4008-5659-6 |page=306}}

The invention of the copper IUD in the 1960s brought with it the capital T-shaped design used by most modern IUDs. U.S. physician Howard Tatum determined that the 'T' shape would work better with the shape of the uterus, which forms a 'T' when contracted. He predicted this would reduce rates of IUD expulsion. Together, Tatum and Chilean physician Jaime Zipper discovered that copper could be an effective spermicide and developed the first copper IUD, TCu200. Improvements by Tatum led to the creation of the TCu380A (ParaGard), which is currently the preferred copper IUD.

The hormonal IUD was also invented in the 1960s and 1970s; initially the goal was to mitigate the increased menstrual bleeding associated with copper and inert IUDs. The first model, Progestasert, was conceived of by Antonio Scommegna and created by Tapani J. V. Luukkainen, but the device only lasted for one year of use. Progestasert was manufactured until 2001.{{cite web |date=March 8, 2003 |title=Contraceptive Concerns |url=http://www.medpundit.blogspot.com/2003_03_02_medpundit_archive.html |access-date=2006-07-16 |website=Medpundit}}{{medrs|date=April 2024}} One commercial hormonal IUD which is currently available, Mirena, was also developed by Luukkainen and released in 1976. The manufacturer of the Mirena, Bayer AG, became the target of multiple lawsuits over allegations that Bayer failed to adequately warn users that the IUD could pierce the uterus and migrate to other parts of the body.{{Cite web |title=Legal Current Events | Westlaw Practitioner Insights |url=http://newsandinsight.thomsonreuters.com/Legal/News/2013/05_-_May/Judge_calls_for_female_lawyers_on_plaintiffs__committee_in_Mirena_MDL/}}

In China, the use of IUDs by state health services was part of the government's efforts to limit birth rates. From 1980 to 2014, 324{{nbsp}}million women were inserted with IUDs, in addition to the 107{{nbsp}}million who had tubal ligation. Women who refused could lose their government employment and their children could lose access to public schools.{{Citation needed|date=August 2023}} The IUDs inserted in this way were modified such that they could not be removed in a doctor's office (meant to be left indefinitely), and surgical removal is usually needed.{{cite news |date=7 January 2017 |title=After One-Child Policy, Outrage at China's Offer to Remove IUDs |url=https://www.nytimes.com/2017/01/07/world/asia/after-one-child-policy-outrage-at-chinas-offer-to-remove-iuds.html |access-date=8 January 2017 |work=The New York Times |vauthors=Wee SL}} Until the mid-1990s, the state-preferred IUD was a stainless steel ring,{{cite web |date=July 14, 2011 |title=Chinese ring |url=http://www.obgyn.net/obgyn-ultrasound/chinese-ring |archive-url=https://web.archive.org/web/20171201041113/http://www.obgyn.net/obgyn-ultrasound/chinese-ring |archive-date=1 December 2017 |access-date=22 November 2017 |website=www.obgyn.net}}{{cite web |title=Intrauterine Devices (IUDs) |url=https://www.fhi360.org/sites/default/files/webpages/Modules/IUD/s1pg6.htm |archive-url=https://web.archive.org/web/20150222032227/http://www.fhi360.org/sites/default/files/webpages/Modules/IUD/s1pg6.htm |archive-date=2015-02-22 |access-date=2017-11-22 |website=www.fhi360.org}} which had a higher rate of complications compared to other types of IUD. It gave rise to the idiom {{lang-zh|c=上环|p=shànghuán|labels=no|out=p}}, meaning "insert a loop". Nowadays, the IUDs include T and V shapes, the former being the most common and easiest to remove.

To implement the two-child policy, the government announced that IUD-removals would be paid for by the government. IUD removals are free for women "who are allowed to have another child" (see one-child policy) or "who cannot continue to have the IUD for health reasons."{{cite web |date=January 13, 2017 |title=One Child Policy Leaves Millions of Chinese Women With Unwanted IUDs |url=http://www.rfa.org/english/women/onechild-iud-01132017173100.html |website=Radio Free Asia |language=en}}

File:Blausen 0585 IUD.png

The main mechanisms of action of IUDs occur prior to fertilization, by preventing sperm from ever reaching the egg.{{Cite web |date=2012-02-17 |title=Myths and facts about... the Intra-Uterine Device (IUD) |url=https://www.ippf.org/blogs/myths-and-facts-about-intra-uterine-devices |access-date=2021-01-18 |website=IPPF |language=en}}

The copper-bearing IUD acts as a spermicide, killing or impairing sperm so they cannot reach the egg. Copper IUDs do not contain any hormones, but release copper ions, which are toxic to sperm. They also cause the uterus and fallopian tubes to produce a fluid that contains white blood cells, copper ions, enzymes, and prostaglandins, which is also toxic to sperm.{{Cite web |date=15 July 2013 |title=Understanding the IUD | Center for Research |url=http://center4research.org/medical-care-for-adults/birth-control/understanding-the-iud/ |archive-url=https://archive.today/20130808133036/http://center4research.org/medical-care-for-adults/birth-control/understanding-the-iud/ |archive-date=2013-08-08 |access-date=2013-08-08 |work=National Center For Health Research}} The very high effectiveness of copper-containing IUDs as emergency contraceptives implies they may also act by preventing implantation of the blastocyst.{{cite book |title=Contraceptive technology |vauthors=Trussell J, Schwarz EB |publisher=Ardent Media |year=2011 |isbn=978-1-59708-004-0 |veditors=Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Kowal D, Policar MS |edition=20th revised |location=New York |pages=113–145 |chapter=Emergency contraception |issn=0091-9721 |oclc=781956734}} p. 121:

Mechanism of action
Copper-releasing IUCs
When used as a regular or emergency method of contraception, copper-releasing IUCs act primarily to prevent fertilization. Emergency insertion of a copper IUC is significantly more effective than the use of ECPs, reducing the risk of pregnancy following unprotected intercourse by more than 99%.^2,3 This very high level of effectiveness implies that emergency insertion of a copper IUC must prevent some pregnancies after fertilization.
Emergency contraceptive pills
To make an informed choice, women must know that ECPs—like the birth control pill, patch, ring, shot, and implant,⁷⁶and even like breastfeeding⁷⁷—prevent pregnancy primarily by delaying or inhibiting ovulation and inhibiting fertilization, but may at times inhibit implantation of a fertilized egg in the endometrium. However, women should also be informed that the best available evidence indicates that ECPs prevent pregnancy by mechanisms that do not involve interference with post-fertilization events.
ECPs do not cause abortion⁷⁸ or harm an established pregnancy. Pregnancy begins with implantation according to medical authorities such as the US FDA, the National Institutes of Health⁷⁹ and the American College of Obstetricians and Gynecologists (ACOG).⁸⁰
Ulipristal acetate (UPA). One study has demonstrated that UP can delay ovulation.⁸¹... Another study found that UPA altered the endometrium, but whether this change would inhibit implantation is unknown.⁸²
p. 122:
Progestin-only emergency contraceptive pills. Early treatment with ECPs containing only the progestin levonorgestrel has been shown to impair the ovulatory process and luteal function.^83–87
p. 123:
Combined emergency contraceptive pills. Several clinical studies have shown that combined ECPs containing ethinyl estradiol and levonorgestrel can inhibit or delay ovulation.^107–110

The progestogen released from hormonal IUDs mainly works by thickening the cervical mucus, preventing sperm from reaching the fallopian tubes. Hormonal IUDs may also sometimes prevent ovulation.{{Cite web |title=Mirena (DIU hormonal) - Mayo Clinic |url=http://www.mayoclinic.org/tests-procedures/mirena/basics/definition/prc-20012867 |website=Mayo Clinic}}

The types of intrauterine devices available, and the names they go by, differ by location. In the United States, there are two types available:{{cite journal | vauthors = | title = IUDs--an update | journal = Population Reports. Series B, Intrauterine Devices | issue = 6 | pages = 1–35 | date = December 1995 | pmid = 8724322 | url = http://www.infoforhealth.org/pr/b6/b6.pdf | access-date = 2006-01-01 | archive-url = https://web.archive.org/web/20060220070054/http://www.infoforhealth.org/pr/b6/b6.pdf | archive-date = 2006-02-20 }}

• Nonhormonal: Copper-containing IUD (ParaGard and others)
• Hormonal: Progestogen-releasing IUD (Mirena and others)

The WHO ATC labels both copper and hormonal devices as IUDs. In the United Kingdom, there are more than 10 different types of copper IUDs available. In the United Kingdom, the term IUD refers only to these copper devices. Hormonal intrauterine contraception is labeled with the term intrauterine system (IUS).{{cite web |title=Contraceptive coils (IUDs) |work=NetDoctor.co.uk |year=2006 |url=http://www.netdoctor.co.uk/sex_relationships/facts/contraceptivecoil.htm |access-date=2006-07-05 |archive-date=17 July 2006 |archive-url=https://web.archive.org/web/20060717035039/http://www.netdoctor.co.uk/sex_relationships/facts/contraceptivecoil.htm |url-status=dead }}{{cite journal | vauthors = French R, Van Vliet H, Cowan F, Mansour D, Morris S, Hughes D, Robinson A, Proctor T, Summerbell C, Logan S, Helmerhorst F, Guillebaud J | title = Hormonally impregnated intrauterine systems (IUSs) versus other forms of reversible contraceptives as effective methods of preventing pregnancy | journal = The Cochrane Database of Systematic Reviews | volume = 2004 | issue = 3 | pages = CD001776 | year = 2004 | pmid = 15266453 | pmc = 8407482 | doi = 10.1002/14651858.CD001776.pub2 | veditors = Sorhaindo AM }}

{{Main|Copper IUDs}}

File:Tête de stérilet.jpg

File:Medical X-Ray imaging NNZ06 nevit.jpg

Most copper IUDs have a T-shaped frame that is wound around with pure electrolytic copper wire and/or has copper collars (sleeves). The arms of the frame hold the IUD in place near the top of the uterus. The Paragard TCu 380a measures 32 mm (1.26") horizontally (top of the T), and 36 mm (1.42") vertically (leg of the T). Copper IUDs have a first year failure rate ranging from 0.1 to 2.2%.{{cite journal | vauthors = Kulier R, O'Brien PA, Helmerhorst FM, Usher-Patel M, D'Arcangues C | title = Copper containing, framed intra-uterine devices for contraception | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD005347 | date = October 2007 | pmid = 17943851 | doi = 10.1002/14651858.CD005347.PUB3 }} They work by damaging sperm and disrupting their motility so that they are not able to join an egg. Specifically, copper acts as a spermicide within the uterus by increasing levels of copper ions, prostaglandins, and white blood cells within the uterine and tubal fluids.{{cite web |title=Mechanisms of the Contraceptive Action of Hormonal Methods and Intrauterine Devices (IUDs) |work=Family Health International |year=2006 |url=http://www.fhi.org/en/RH/Pubs/booksReports/methodaction.htm |access-date=2006-07-05 }} The increased copper ions in the cervical mucus inhibit the sperm's motility and viability, preventing sperm from traveling through the cervical mucus, or destroying it as it passes through.{{cite journal | vauthors = Ortiz ME, Croxatto HB | title = Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action | journal = Contraception | volume = 75 | issue = 6 Suppl | pages = S16–S30 | date = June 2007 | pmid = 17531610 | doi = 10.1016/j.contraception.2007.01.020 }} Copper can also alter the endometrial lining, and while studies show that while this alteration can prevent implantation of a fertilized egg ("blastocyst"), it cannot disrupt one that has already been implanted.{{cite web | title = Facts are Important: Emergency Contraception (EC) and Intrauterine Devices (IUDs) are Not Abortifacients | publisher = American Congress of Obstetricians and Gynecologists | date = June 12, 2014 | url = http://www.acog.org/-/media/Departments/Government-Relations-and-Outreach/FactsAreImportantEC.pdf?dmc=1&ts=20150127T1149330103 | format = PDF | access-date = July 14, 2015 |quote=Copper ions released from the IUD create an environment that is toxic to sperm, preventing fertilization.14 Copper can also alter the endometrial lining, but studies show that this alteration can prevent implantation, but not disrupt implantation}}

Advantages of the copper IUD include its ability to provide emergency contraception up to five days after unprotected sex. It is the most effective form of emergency contraception available.{{cite journal | vauthors = Cleland K, Zhu H, Goldstuck N, Cheng L, Trussell J | title = The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience | journal = Human Reproduction | volume = 27 | issue = 7 | pages = 1994–2000 | date = July 2012 | pmid = 22570193 | pmc = 3619968 | doi = 10.1093/humrep/des140 | doi-access = free }} It works by preventing fertilization or implantation but does not affect already implanted embryos. It contains no hormones, so it can be used while breastfeeding, and fertility returns quickly after removal.{{cite journal | vauthors = Belhadj H, Sivin I, Diaz S, Pavez M, Tejada AS, Brache V, Alvarez F, Shoupe D, Breaux H, Mishell DR | title = Recovery of fertility after use of the levonorgestrel 20 mcg/d or Copper T 380 Ag intrauterine device | journal = Contraception | volume = 34 | issue = 3 | pages = 261–267 | date = September 1986 | pmid = 3098498 | doi = 10.1016/0010-7824(86)90007-7 }}

Copper IUDs also last longer and are available in a wider range of sizes and shapes than hormonal IUDs. Disadvantages include the possibility of heavier menstrual periods and more painful cramps.

IUDs that contain gold or silver also exist.{{cite web |author=Schering |date=May 13, 2003 |title=Nova T380 Patient information leaflet (PIL) |url=http://emc.medicines.org.uk/emc/assets/c/html/displaydoc.asp?documentid=3641 |access-date=2007-04-27 |archive-url=https://web.archive.org/web/20070928060627/http://emc.medicines.org.uk/emc/assets/c/html/displaydoc.asp?documentid=3641 |archive-date=September 28, 2007 |df=mdy-all |author-link=Schering AG }} Other shapes of IUD include the so-called U-shaped IUDs, such as the Load and Multiload, and the frameless IUD that holds several hollow cylindrical minuscule copper beads. It is held in place by a suture (knot) to the fundus of the uterus. It is mainly available in China and Europe. A framed copper IUD called the IUB SCu300 coils when deployed and forms a three-dimensional spherical shape. It is based on a nickel titanium shape memory alloy core.{{cite journal | vauthors = Baram I, Weinstein A, Trussell J | title = The IUB, a newly invented IUD: a brief report | journal = Contraception | volume = 89 | issue = 2 | pages = 139–141 | date = February 2014 | pmid = 24309220 | pmc = 3947156 | doi = 10.1016/j.contraception.2013.10.017 }} In addition to copper, noble metal, and progestogen IUDs, women in China can get copper IUDs with indomethacin. This non-hormonal compound reduces the severity of menstrual bleeding, and these coils are popular.{{cite journal | vauthors = Li Y, Zhang SM, Chen F, Zhang CY, Li YP, Zhou J, Xun PC, Zhao Y, Ba L, Wang L, Wu YL, Xu JX, Yu SQ, Li L, Zhang YJ, Yu GB, Fang AH, Huang JT, Tian AP, Chen HP | title = [A multi-center randomized controlled trial of intrauterine device use in Chinese women] | language = zh | journal = Zhonghua Yi Xue Za Zhi | volume = 91 | issue = 45 | pages = 3172–3175 | date = December 2011 | pmid = 22333096 }}

Inert IUDs do not have a bioactive component. They are made of inert materials like stainless steel (such as the stainless steel ring (SSR), a flexible ring of steel coils that can deform to be inserted through the cervix) or plastic (such as the Lippes Loop, which can be inserted through the cervix in a cannula and takes a trapezoidal shape within the uterus). They are less effective than copper or hormonal IUDs, with a side effect profile similar to copper IUDs. Their primary mechanism of action is inducing a local foreign body reaction, which makes the uterine environment hostile both to sperm and to implantation of an embryo. They may have higher rates of preventing pregnancy after fertilization, instead of before fertilization, compared to copper or hormonal IUDs.{{cite journal | title = Intrauterine devices and intrauterine systems | journal = Human Reproduction Update | volume = 14 | issue = 3 | pages = 197–208 | date = April 2008 | pmid = 18400840 | doi = 10.1093/humupd/dmn003 | doi-access = free | author1 = ESHRE Capri Workshop Group }}

Inert IUDs are not yet approved for use in the United States, UK, or Canada. In China, where IUDs are the most common form of contraception, copper IUD production replaced inert IUD production in 1993.{{cite journal | vauthors = Bilian X | title = Chinese experience with intrauterine devices | journal = Contraception | volume = 75 | issue = 6 Suppl | pages = S31–S34 | date = June 2007 | pmid = 17531613 | doi = 10.1016/j.contraception.2006.12.007 }} However, as of 2008, the most common IUD used by immigrants presenting to Canadian clinics for removal of IUDs placed in China was still the SSR. Because the SSR has no string for removal, it can present a challenge to healthcare providers unfamiliar with IUD types not available in their region.{{cite journal | vauthors = Cheung VY | title = A 10-year experience in removing Chinese intrauterine devices | journal = International Journal of Gynaecology and Obstetrics | volume = 109 | issue = 3 | pages = 219–222 | date = June 2010 | pmid = 20219193 | doi = 10.1016/j.ijgo.2009.12.018 | s2cid = 8020802 }}

{{Main|Hormonal IUDs}}

File:Mirena IntraUterine System.jpg (Mirena)]]

Hormonal IUDs (referred to as intrauterine systems in the UK) work by releasing a small amount of levonorgestrel, a progestin. Each type varies in size, amount of levonorgestrel released, and duration. The primary mechanism of action is making the inside of the uterus uninhabitable for sperm.{{cite book| vauthors = Speroff L, Darney PD |year=2011|chapter=Intrauterine contraception|title=A clinical guide for contraception|edition=5th|location=Philadelphia|publisher=Lippincott Williams & Wilkins|pages=239–280|isbn=978-1-60831-610-6}} pp. 246–247:

Mechanism of action
The contraceptive action of all IUDs is mainly in the intrauterine cavity. Ovulation is not affected, and the IUD is not an abortifacient.^58–60 It is currently believed that the mechanism of action for IUDs is the production of an intrauterine environment that is spermicidal.
Nonmedicated IUDs depend for contraception on the general reaction of the uterus to a foreign body. It is believed that this reaction, a sterile inflammatory response, produces tissue injury of a minor degree but sufficient to be spermicidal. Very few, if any, sperm reach the ovum in the fallopian tube.
The progestin-releasing IUD adds the endometrial action of the progestin to the foreign body reaction. The endometrium becomes decidualized with atrophy of the glands.⁶⁵ The progestin IUD probably has two mechanisms of action: inhibition of implantation and inhibition of sperm capacitation, penetration, and survival.

The progestin released by hormonal IUDs primarily acts locally; use of Mirena results in much lower systemic progestin levels than other very-low-dose progestogen only contraceptives.{{cite journal | vauthors = Malik S | title = Levonorgestrel-IUS system and endometrial manipulation | journal = Journal of Mid-Life Health | volume = 4 | issue = 1 | pages = 6–7 | date = January 2013 | pmid = 23833526 | pmc = 3702070 | doi = 10.4103/0976-7800.109625 | doi-access = free }}

File:IUD nulliparous cervix.jpg woman. Image was taken immediately after insertion and injection of lidocaine.]]

It is difficult to predict what a woman will experience during IUD insertion or removal. Some women describe the insertion as cramps, some as a pinch, and others do not feel anything. Only 9% of nulliparous women considered the procedure painless, 72% moderately painful, and 17% experience substantial pain with insertion that needs active management.{{cite journal |vauthors=Marions L, Lövkvist L, Taube A, Johansson M, Dalvik H, Øverlie I |date=April 2011 |title=Use of the levonorgestrel releasing-intrauterine system in nulliparous women--a non-interventional study in Sweden |journal=The European Journal of Contraception & Reproductive Health Care |volume=16 |issue=2 |pages=126–134 |doi=10.3109/13625187.2011.558222 |pmid=21417562 |s2cid=43266521}} Approximately 11% of parous women feel similar pain.{{cite journal |vauthors=Gemzell-Danielsson K, Mansour D, Fiala C, Kaunitz AM, Bahamondes L |year=2013 |title=Management of pain associated with the insertion of intrauterine contraceptives |journal=Human Reproduction Update |volume=19 |issue=4 |pages=419–427 |doi=10.1093/humupd/dmt022 |pmc=3682672 |pmid=23670222}} In such cases, NSAIDs can be effective when given in response to post-insertion pain, but have no significant effect when given prophylactically. Topical lidocaine has been found as an effective pain management drug when applied before the procedure.{{cite journal |vauthors=Karasu Y, Cömert DK, Karadağ B, Ergün Y |date=June 2017 |title=Lidocaine for pain control during intrauterine device insertion |journal=The Journal of Obstetrics and Gynaecology Research |volume=43 |issue=6 |pages=1061–1066 |doi=10.1111/jog.13308 |pmid=28503818 |s2cid=4762488}} The use of intrauterine lidocaine (paracervical block) is underutilized in the United States as an effective method to reduce pain associated with insertion.{{Cite web |title=Why haven't we figured out how to make IUDs less excruciating? |url=https://www.motherjones.com/politics/2022/06/why-are-iuds-so-painful-treatment-contraception-roe-dobbs-supreme-court/ |access-date=2023-01-18 |website=Mother Jones |language=en-US |vauthors=Murai R}}

IUD insertion can occur at multiple timepoints in a woman's reproductive lifespan:

1. interval insertion, the most common, occurs remote from pregnancy;
2. post-abortion or post-miscarriage insertion occurs following an abortion or miscarriage when the uterus is known to be empty;
3. postpartum insertion occurs after a woman gives birth either immediately, while the woman is still in the hospital, or delayed, up to 6-weeks following delivery, following either vaginal delivery or cesarean delivery. Insertion timing changes the risk of IUD expulsion.{{Cite web |title=Long-Acting Reversible Contraception: Implants and Intrauterine Devices |url=https://www.acog.org/en/Clinical/Clinical%20Guidance/Practice%20Bulletin/Articles/2017/11/Long-Acting%20Reversible%20Contraception%20Implants%20and%20Intrauterine%20Devices |access-date=2020-04-13 |website=www.acog.org |language=en}}{{cite journal |vauthors=Okusanya BO, Oduwole O, Effa EE |date=July 2014 |title=Immediate postabortal insertion of intrauterine devices |journal=The Cochrane Database of Systematic Reviews |volume=2014 |issue=7 |pages=CD001777 |doi=10.1002/14651858.cd001777.pub4 |pmc=7079711 |pmid=25101364}}{{Cite web |title=Early Pregnancy Loss |url=https://www.acog.org/en/Clinical/Clinical%20Guidance/Practice%20Bulletin/Articles/2018/11/Early%20Pregnancy%20Loss |access-date=2020-04-13 |website=www.acog.org |language=en}}{{cite journal |vauthors=Lopez LM, Bernholc A, Hubacher D, Stuart G, Van Vliet HA |date=June 2015 |title=Immediate postpartum insertion of intrauterine device for contraception |journal=The Cochrane Database of Systematic Reviews |volume=2015 |issue=6 |pages=CD003036 |doi=10.1002/14651858.cd003036.pub3 |pmc=10777269 |pmid=26115018 |doi-access=free}}{{cite journal |vauthors=Jatlaoui TC, Whiteman MK, Jeng G, Tepper NK, Berry-Bibee E, Jamieson DJ, Marchbanks PA, Curtis KM |date=October 2018 |title=Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis |journal=Obstetrics and Gynecology |volume=132 |issue=4 |pages=895–905 |doi=10.1097/aog.0000000000002822 |pmc=6549490 |pmid=30204688}}

During the insertion procedure, health care providers use a speculum to find the cervix (the opening to the uterus), pinch the cervix to stabilize it open with a tenaculum,{{cite journal |vauthors=Johnson BA |date=January 2005 |title=Insertion and removal of intrauterine devices |url=https://www.aafp.org/afp/2005/0101/p95.html |journal=American Family Physician |volume=71 |issue=1 |pages=95–102 |pmid=15663031}} and then use an insertion device to place the IUD in the uterus. The insertion device goes through the cervix. The procedure itself, if uncomplicated, should take no more than five to ten minutes.{{Cite web |title=What's an IUD insertion like? |url=https://www.plannedparenthood.org/learn/birth-control/iud/whats-an-iud-insertion-like |access-date=2018-03-29 |website=www.plannedparenthood.org |language=en}}

A suction cervical stabilizer can be used in place of the standard tenaculum to hold the cervix open during the IUD insertion procedure.{{Cite journal |last1=Yaron |first1=Michal |last2=Legardeur |first2=Hélène |last3=Barcellini |first3=Bastien |last4=Akhoundova |first4=Farida |last5=Mathevet |first5=Patrice |date=2023-07-01 |title=Safety and efficacy of a suction cervical stabilizer for intrauterine contraceptive device insertion: Results from a randomized, controlled study |url=https://www.sciencedirect.com/science/article/pii/S0010782423000665 |journal=Contraception |volume=123 |pages=110004 |doi=10.1016/j.contraception.2023.110004 |issn=0010-7824 |pmid=36914147}} Suction cervical stabilizers, such as The Carevix™ Suction Cervical Stabilizer,{{Cite web |title=510(k) Premarket Notification |url=https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?ID=K223866 |access-date=2025-01-05 |website=www.accessdata.fda.gov}} may reduce pain associated with the insertion procedure.{{Cite web |last=Ansanay-Alex |first=Sandra |date=2023-02-07 |title=Aspivix receives U.S. FDA Clearance for Carevix™, Their Novel Cervical Stabilizer |url=https://bioalps.org/aspivix-receives-fda-clearance-carevix-cervical-stabilizer/ |access-date=2025-01-05 |website=BioAlps |language=en-US}}

For immediate postpartum insertion, the IUD is inserted following the removal of the placenta from the uterus. The uterus is larger than baseline following birth, which has important implications for insertion. After vaginal deliveries, insertions can be done using placental forceps, a longer inserter specialized for postpartum insertions, or manually, where the provider uses their hand to insert the IUD in the uterus. After cesarean deliveries, the IUD is placed in the uterus with forceps or manually during surgery prior to suturing the uterine incision.{{cite journal |vauthors=Whitaker AK, Chen BA |date=January 2018 |title=Society of Family Planning Guidelines: Postplacental insertion of intrauterine devices |journal=Contraception |volume=97 |issue=1 |pages=2–13 |doi=10.1016/j.contraception.2017.09.014 |pmid=28987293 |doi-access=free}}

Generally, the removal is uncomplicated and reported to be not as painful as the insertion because there is no instrument that needs to go through the cervix.{{Cite news |title=This Is What to Expect After Getting Your IUD Removed |url=https://www.self.com/story/iud-removal-facts |access-date=2018-03-30 |work=SELF |language=en |vauthors=Barnes Z}} This process requires the health care provider to find the cervix with a speculum and then use ring forceps, which only go into the vagina, to grasp the IUD strings and then pull the IUD out.

IUD placement and removal can be taught both by manufacturers and other training facilities.{{Cite web |title=Clinical Education and Training |url=https://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/LARC-Clinician-Education-and-Training |access-date=2019-08-21 |website=www.acog.org |language=en}}

{{Further|IUD with progestogen|IUD with copper|Progestogen (medication)#Side effects|Progestogen (medication)#Mood changes}}

File:Perforated IUD.jpg showing a perforated copper IUD as a hyperechoic (rendered as bright) line at right, {{cvt|30|mm}} away from the uterus at left. The IUD is surrounded by a hypoechoic (dark) foreign-body granuloma.]]

Regardless of IUD type, there are some potential side effects that are similar for all IUDs. Some of these side effects include bleeding pattern changes, expulsion, and pelvic inflammatory disease (especially in the first 21 days after insertion). The occurrence of IUD migration is rare, with reported rates in medical literature varying between 0.1% and 0.9%. However, when migration occurs, it can lead to serious complications such as uterine perforation and, in rare cases, bladder perforation. Bladder perforation, while uncommon (affecting only 2% of displaced IUDs), can result in symptoms like urinary frequency, hematuria, and stone formation, often necessitating surgical intervention for removal.{{Cite journal |last1=Liu |first1=Guangtao |last2=Li |first2=Feifei |last3=Ao |first3=Min |last4=Huang |first4=Guimin |date=2021-08-16 |title=Intrauterine devices migrated into the bladder: two case reports and literature review |journal=BMC Women's Health |volume=21 |issue=1 |pages=301 |doi=10.1186/s12905-021-01443-w |doi-access=free |issn=1472-6874 |pmc=8365895 |pmid=34399735}} Regular monitoring and imaging, such as ultrasound or CT scans, are recommended to detect such complications early and ensure timely treatment. A small probability of pregnancy remains after IUD insertion, and when it occurs, there is a greater risk of ectopic pregnancy.{{cite web |title=ParaGard (copper IUD) |url=https://www.mayoclinic.org/tests-procedures/paragard/about/pac-20391270 |website=Mayo Clinic |access-date=30 November 2018}}

IUDs with progestogen confer an increased risk of ovarian cysts,{{cite journal | vauthors = Bahamondes L, Hidalgo M, Petta CA, Diaz J, Espejo-Arce X, Monteiro-Dantas C | title = Enlarged ovarian follicles in users of a levonorgestrel-releasing intrauterine system and contraceptive implant | journal = The Journal of Reproductive Medicine | volume = 48 | issue = 8 | pages = 637–640 | date = August 2003 | pmid = 12971147 }} and IUDs with copper confer an increased risk of heavier periods. Mirena lists among its side effects mental health changes including nervousness, depressed mood, or mood swings.{{cite web |date=March 2014 |title=Mirena: Consumer Medicine Information |url=http://www.bayerresources.com.au/resources/uploads/CMI/file9398.pdf |url-status=live |archive-url=https://web.archive.org/web/20140427203913/http://www.bayerresources.com.au/resources/uploads/CMI/file9398.pdf |archive-date=27 April 2014 |access-date=27 April 2014 |publisher=Bayer}}

Menstrual cup companies recommend that women with IUDs who are considering using menstrual cups should consult with their gynecologists before use. There have been rare cases in which women using IUDs dislodged them when removing their menstrual cups, however, this can also happen with tampon use.{{cite web |url=http://www.femininewear.co.uk/cup-use-and-iuds-24-w.asp |title=Menstrual Cup use and IUDs |publisher=Feminine Wear |access-date=22 December 2013 |archive-url=https://web.archive.org/web/20170713105724/http://www.femininewear.co.uk/cup-use-and-iuds-24-w.asp |archive-date=13 July 2017 }} Despite reports, as of 2023, there is no scientific agreement on whether using a menstrual cup increases the risk of IUD expulsion; more rigorous studies are needed.{{cite journal | vauthors = Bowman N, Thwaites A | title = Menstrual cup and risk of IUD expulsion - a systematic review | journal = Contraception and Reproductive Medicine | volume = 8 | issue = 1 | pages = 15 | date = January 2023 | pmid = 36670496 | pmc = 9863186 | doi = 10.1186/s40834-022-00203-x | doi-access = free }}

Unlike condoms, the IUD does not protect against sexually transmitted infections.{{cite web|title=What Are the Side Effects & Complications of the IUD?|url=https://www.plannedparenthood.org/learn/birth-control/iud/what-are-the-disadvantages-of-iuds|website=www.plannedparenthood.org|access-date=21 November 2017|language=en}}

Modern IUDs do not lead to infertility or make it harder for a woman to become pregnant, and fertility typically returns within days of removal. Some prior studies found an association between infertility and the Dalkon Shield, an early IUD design which is no longer available.{{Cite book|url=https://books.google.com/books?id=ZQehCgAAQBAJ&q=infertility+and+iud&pg=PA273|title=The Handbook of Contraception: A Guide for Practical Management| vauthors = Shoupe D, Mishell Jr DR |date=2015-09-28|publisher=Humana Press|isbn=978-3-319-20185-6|language=en}}

Modern IUDs do not cause increased infection, though the earlier Dalkon Shield may have, because it contained multifilament strings, which provided bacteria a space to grow and move up the string. IUDs manufactured after 2008 use monofilament strings in order to prevent this from happening.{{Cite book|url=https://books.google.com/books?id=v4krPhqFG8sC&q=COPPER+AND+MIRENA+MONOFILAMENT&pg=PA529|title=Danforth's Obstetrics and Gynecology| vauthors = Gibbs RS |date=2008|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-6937-2|language=en}} However, as with any medical intervention, IUDs can lead to increased risk of infection immediately after the insertion.

According to the U.S. Medical Eligibility Criteria for Contraceptive Use, published by the CDC, women and adolescents under the age of 20 and women who have not given birth are classified in category 2 for IUD use, mainly due to "the risk for expulsion from nulliparity and for STDs from sexual behavior in younger age groups." According to the CDC, benefits generally outweigh the risks, and IUDs are recommended for young and nulliparous women, although more careful attention may be required. Women over age 20 and those who have previously given birth are placed in category 1, meaning no special concerns are placed on use.{{Cite web|url=https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendixb.html|title=Classifications for Intrauterine Devices|website=www.cdc.gov|date=9 April 2020 |access-date=4 August 2022}}{{cite journal | vauthors = Curtis KM, Tepper NK, Jatlaoui TC, Berry-Bibee E, Horton LG, Zapata LB, Simmons KB, Pagano HP, Jamieson DJ, Whiteman MK | title = U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 | language = en-us | journal = MMWR. Recommendations and Reports | volume = 65 | issue = 3 | pages = 1–103 | date = July 2016 | pmid = 27467196 | doi = 10.15585/mmwr.rr6503a1 | doi-access = free }}

Some women experience amenorrhea, or lack of menstruation while using an IUD. Menstruation occurs when a woman has not become pregnant and the uterus sheds its lining in preparation for the next cycle. IUDs tend to thin the lining of the uterus, leading to less menses by volume or a lack of menstruation altogether. There is a condition known as polycystic ovarian syndrome (PCOS) which causes women to miss their periods and can lead to an increased risk of endometrial cancer.{{cite journal | vauthors = Dumesic DA, Lobo RA | title = Cancer risk and PCOS | journal = Steroids | volume = 78 | issue = 8 | pages = 782–785 | date = August 2013 | pmid = 23624028 | doi = 10.1016/j.steroids.2013.04.004 | s2cid = 10185317 }} However, an IUD causes the endometrial lining of a uterus to thin, which is the opposite of what occurs with PCOS.  

Levonorgestrel intrauterine devices (LNG-IUDs) have been associated with psychiatric symptoms, including depression, anxiety, and suicidal ideation, particularly in adolescents and young women, though evidence remains mixed. Some studies report increased depressive symptoms and anxiety, potentially linked to the sensitization of the hypothalamic-pituitary-adrenal (HPA) axis and elevated cortisol levels, while others find no association or even reduced symptoms.

Globally, 14.3% of married or partnered women of reproductive age (15–49) use intrauterine contraception as their preferred method of family planning. And a study found that female family planning providers choose LARC methods more often (41.7%) than the general public (12.1%).{{Cite web |title=New Study Finds Women's Health Providers Use IUDs More Than Any Other Method of Birth Control |url=https://www.plannedparenthood.org/about-us/newsroom/press-releases/new-study-finds-womens-health-providers-use-iuds-more-than-any-other-method-of-birth-control |access-date=2018-03-27 |website=www.plannedparenthood.org |language=en}} However, the adoption of IUC varies significantly across different regions. In Asia, IUC is particularly popular, with 27% of contraceptive users relying on it, while in Oceania, the usage rate is much lower at 1.8%. Geographically, the majority of IUC users—over 80% worldwide—are concentrated in Asia, with nearly two-thirds (64%) of these users living in China.{{Cite journal |last1=Buhling |first1=Kai J. |last2=Zite |first2=Nikki B. |last3=Lotke |first3=Pamela |last4=Black |first4=Kirsten |date=2014-03-01 |title=Worldwide use of intrauterine contraception: a review |url=https://www.sciencedirect.com/science/article/pii/S0010782413007336 |journal=Contraception |volume=89 |issue=3 |pages=162–173 |doi=10.1016/j.contraception.2013.11.011 |pmid=24369300 |issn=0010-7824|doi-access=free }}

IUC use is more prevalent in less developed regions (15.1% of women) compared to more developed regions (9.2% of women). Within continents, there are significant variations. For instance, in Europe, IUC usage ranges from 5% in Southern Europe to 16–28% in countries like France and Scandinavia. In Africa, IUC use is relatively low in sub-Saharan regions (less than 2%) but higher in Northern Africa, particularly in countries such as Egypt (36.1%) and Tunisia (27.8%). In the United States, the use of IUDs increased from 0.8% in 1995 to 7.2% from the period of 2006 to 2014.{{Cite web |title=Products - Data Briefs - Number 188 - February 2015 |url=https://www.cdc.gov/nchs/data/databriefs/db188.htm |access-date=2018-03-27 |website=www.cdc.gov |language=en-us}}{{Cite web |date=2004-08-04 |title=Contraceptive Use in the United States |url=https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states |access-date=2019-04-19 |website=Guttmacher Institute |language=en}} IUC usage rates are also influenced by ethnicity within United States, with Hispanic women more likely to use IUC compared to Caucasian women.

Among birth control methods, IUDs, along with other contraceptive implants, result in the greatest satisfaction among users.

In the United States, intrauterine devices (IUDs) typically cost between $0 and $1,300, with prices covering medical exams, insertion, and follow-up visits.{{Cite web |title=IUD Birth Control {{!}} Info About Mirena & ParaGard IUDs |url=https://www.plannedparenthood.org/learn/birth-control/iud |access-date=2018-12-02 |website=www.plannedparenthood.org |language=en}} Under the Affordable Care Act, most insurance plans must cover all FDA-approved birth control methods, including IUDs, though coverage for specific brands may vary.{{Cite web |title=Where Can I Buy the IUD & How Much Will It Cost? |url=https://www.plannedparenthood.org/learn/birth-control/iud/how-can-i-get-an-iud |access-date=2019-03-27 |website=www.plannedparenthood.org |language=en}}

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